Three Wishes: What Claims Adjusters Really Want Claims professionals in the workers’ compensation industry have seen their jobs become increasingly more complex. One Call Medical, the national leader in diagnostic management, recently hosted a series of focus groups with claims adjusters to identify their work life “wish list.” The top three items on this collective list were: 1) education, 2) increased productivity, and 3) ongoing guidance to improve results, particularly in regards to quality, costs, and outcomes. This bulletin focuses on adjusters’ work-related challenges and the solutions available to meet their needs. Claims professionals in the workers’ compensation industry are managing a larger number of open cases while faced with changes in legislation, regulations and reductions in staff more than ever before. The sheer volume of work has made it difficult for many adjusters to properly manage claims for optimum efficiency, cost-containment, and outcomes.
The Facts: Due to the depth of knowledge that claims adjusters require, their number one demand is for more training and education.
To understand the scope and depth of their workrelated challenges, One Call Medical recently held several focus groups with claims adjusters, which revealed the three things claims professionals want most in order to perform their jobs more effectively:
Teach Me. Most states require licensed certification to practice, as well as a certain number of continuing education units (CEU) each year to maintain this license. By designing or offering courses that qualify for CEU credits, payers can provide their adjusters with more in-depth expertise, while also helping them to achieve their state-mandated CEU requirements. Make Me More Efficient. Claims adjusters typically handle anywhere from 150 and 250 claims at any given time. Unfortunately, the claims management process has progressed very little over the years and still requires tedious manual data entry, time-consuming administrative tasks, and other labor-intensive processes. As a result, their second wish is to streamline workflow in order to efficiently and effectively handle their caseloads.
Help Me Perform Better. Although the claims profession continues to evolve, the core mission of the adjuster remains the same: to control costs, ensure claimants receive quality medical care, and return employees to work as soon as possible. To achieve these objectives, adjusters want a more structured approach to help them understand and improve their claims-management performance.
The Facts: An analytic and consultative approach enables adjusters to positively impact their own claims-management performance.
One Call Medical has identified the following key strategies, tools, and solutions to help meet adjusters’ needs:
Online Training and Education. Webinars and other self-paced online learning modules will provide adjusters with specialized knowledge and expertise, along with state certification-required CEUs. Online training opportunities also allow payers and third party administrators (TPAs) to reach a broad audience of claims adjusters in a very cost effective manner. Outsourced Services and Productivity Tools. By outsourcing specialized services and utilizing web-based tools, adjusters can move claims through the adjudication process with greater efficiency. By handing off specialized functions, adjusters can focus their time on the claims that most require their expert knowledge and personal oversight. Ongoing Consultation. An analytic and consultative approach enables adjusters to improve their own claims-management performance. Payers can expedite this process by helping adjusters identify and improve the processes, procedures, and behaviors that will lead to measurable program improvements, particularly in regards to quality, costs, and outcomes.
ANCHOR POINT
PART 2: Making Adjusters’ Wish List Come True: Education, Productivity Tools, and Guidance The demand for qualified and experienced claims examiners is greater than ever. One Call Medical is helping payers and third-party administrators (TPAs) to satisfy adjusters’ top “three wishes” — for education, productivity tools, and guidance — in order to attract and retain the industry’s most talented claims professionals. Wish #1: Training to Do My Job with More Knowledge Due to the depth of knowledge that adjusters require, their number one demand is for more training and education. Most states require licensed certification to practice, as well as a certain number of continuing education credits (CEU) each year to maintain this license. In addition, their jobs require them to become knowledgeable about a number of complex topics, such as liability, compensation, litigation, medical terminology, and loss-prevention strategies.
The Facts: Many payers have begun to leverage webinars and Internet capabilities to train a large, geographically dispersed staff of adjusters.
Many payers are now working with partners to design and deliver educational material and training sessions that help claims adjusters develop greater expertise on various aspects of claims management. By designing courses that qualify for CEU credits, payers also help adjusters fulfill their continuing education requirements.
A number of national payers have begun to leverage webinars and other internet capabilities to train a large, geographically disperse staff of adjusters. For example, they may post training materials and self-paced learning modules on web portals, so adjusters can easily log on to access educational information. One Call Medical has partnered with national payers and TPAs to deliver training sessions on the need for and benefits of diagnostic claims management. Most recently, One Call Medical launched a series of webinars and continuing education units (CEUs) that help the industry understand and address complex diagnostic testing challenges. These training opportunities are now available online through the new OCM University. To register and view a calendar of events, go to www.onecallmedical.com, enter the OCM Knowledge Center, and select Webinars/CEUs, or simply contact One Call Medical at the information below. Training enables adjusters to perform their jobs with more in-depth expertise about today’s diagnostic challenges and available solutions, such as using a network of qualified physicians and testing facilities that consistently deliver medically useful reports.
Wish #2: Services and Tools to Do My Job with More Efficiency In a typical claims department, adjusters may handle 150 to 250 claims at any given time. Many claim departments still use outdated manual data entry and a paper-based workflow. Claims adjusters end up wasting a significant amount of time on routine administrative tasks that have little impact on the costs or outcome of a claim. As a result, their second wish is to utilize outsourced services and productivity tools that enable them to streamline workflow and more effectively handle their caseloads.
The Facts: In a typical claims department, adjusters may handle 150 to 250 claims at any given time.
Outsourcing Specialized Services. Payers have segmented the claims process so various experts handle specialized tasks. For example, by partnering with One Call Medical, payers and adjusters can delegate their entire diagnostic referral process --- they no longer have to worry about identifying the provider, scheduling the appointment, or following up on the report or bill. One Call Medical handles the whole process. At the same time, adjusters can rest assured that One Call Medical is working on behalf of injured workers as well. Experienced care coordinators assist in selecting diagnostic providers conveniently located for patients, which reduces the number of testing delays and appointment no-shows. Online Productivity Tools. With a growing volume of claims, improved efficiency is more critical than ever. Payers can provide adjusters with tools to automate and streamline routine administrative tasks and labor-intensive manual functions, freeing them to focus their attention where it’s needed most. Tools such as web-based technology can make a major contribution to improved adjuster productivity. One Call Medical provides adjusters with a complete set of electronic capabilities that streamline the diagnostic referral process. Its online “Customer Center” provides adjusters with 24-hour access to the status of their diagnostic claims and easily retrievable medical report information in a secure data environment. The company’s integrated eResponse solution provides claims professionals efficient and effective electronic communications detailing referral and appointment notifications as well as medical reports. These web-based capabilities help adjusters move diagnostic claims through the system with maximum workflow efficiency. As an example, here’s how some of these functions work as a time-saving device. An adjuster is automatically emailed appointment confirmation, rescheduling notification, and scheduling information. Following an injured employee’s appointment, One Call Medical secures the medical report from
the imaging center and electronically distributes the report back to the adjuster via e-Response. This not only reduces the time adjusters spend on administrative work, it also gives them convenient online access to diagnostic claims information whenever they need it. Wish #3: Reducing Claims Leakage to Improve Quality, Costs, & Outcomes The primary mission of claims professionals is to control costs, ensure claimants receive appropriate medical care, and facilitate optimal outcomes, such as early return-to-work. One of their biggest challenges is not being able to quantify claims leakage—namely the wasteful overpayments that leech funds from a payer’s bottom line. Since adjusters are held accountable for their claims-management performance, their third wish is for continual feedback and guidance in identifying specific areas of improvement.
The Facts: One of the biggest challenges is not being able to quantify claims leakage—namely the wasteful overpayments that leech funds from a payer’s bottom line.
Many payers are unaware of how much they spend on high-end radiology services, or what percentage of their claims are unmanaged. In some cases, the claims examiner or nurse case manager may schedule an MRI or CT directly with an imaging facility—missing the opportunity to leverage diagnostic network savings and management. • To further reduce claims leakage, payers must educate claims adjusters, nurse case managers and treating physicians on the proper procedures to schedule diagnostic services for injured employees. Initial treating physicians often schedule exams directly with out-of-network providers; a contributing factor in leakage. Advanced communication tools now enable claims adjusters to automatically connect the physician with a diagnostic scheduling agent. Adjusters realize that by using a specialized preferred provider network for diagnostic services, injured employees are referred to only the best providers who can consistently deliver accurate test results and diagnoses and more effective treatment plans. When injured workers recover and return to work quickly and safely, these results are reflected in an adjuster’s overall job performance. Finally, sophisticated networks can also identify the 10 to 15 percent of services that have already been performed, but still qualify for discounts. This retrospective savings process minimizes losses by re-pricing bills and reconciling payments with providers who have agreed to participate.
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With this valuable information, adjusters are empowered to consistently apply the processes, procedures, and behaviors that positively impact quality, costs, and outcomes.
A Partner Dedicated to Delivering Results The demand for knowledgeable, experienced claims professionals has never been greater. The shortage of new adjusters entering the field may reach a crisis point in the near future. With this in mind, it’s imperative that payers take the necessary steps to make these “three wishes” a reality in order to attract and retain today’s top talent. By meeting these needs, adjusters will be better able to perform their jobs more effectively and experience greater career satisfaction.
The Facts: Payers must take the necessary steps to grant these “three wishes” if they hope to attract and retain today’s top talent.
One Call Medical is committed to providing its clients with measurable diagnostic improvements, as well as offering their claims management staff with the training, diagnostic services, web-based technology, and analytic consultation they require to achieve outstanding results. This level of partnership is unmatched in today’s marketplace, making One Call Medical the provider of choice in the diagnostic testing industry.